Association between age and access to immediate breast reconstruction in women undergoing mastectomy for breast cancer.

BACKGROUND: National guidelines state that patients with breast cancer undergoing mastectomy in England should be offered immediate breast reconstruction (IR), unless precluded by their fitness for surgery or the need for adjuvant therapies. METHODS: A national study investigated factors that influenced clinicians' decision to offer IR, and collected data on case mix, operative procedures and reconstructive decision-making among women with breast cancer having a mastectomy with or without IR in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between whether or not women were offered IR and their characteristics (tumour burden, functional status, planned radiotherapy, planned chemotherapy, perioperative fitness, obesity, smoking status and age). RESULTS: Of 13 225 women, 6458 (48·8 per cent) were offered IR. Among factors the guidelines highlighted as relevant to decision-making, the three most strongly associated with the likelihood of an offer were tumour burden, planned radiotherapy and performance status. Depending on the combination of their values, the probability of an IR offer ranged from 7·4 to 85·1 per cent. A regression model that included all available factors discriminated well between whether or not women were offered IR (c-statistic 0·773), but revealed that increasing age was associated with a fall in the probability of an IR offer beyond that expected from older patients' tumour and co-morbidity characteristics. CONCLUSION: Clinicians are broadly following guidance on the offer of IR, except with respect to patients' age

Barriers and facilitators to implementing workplace health and wellbeing services in the NHS from the perspective of senior leaders and wellbeing practitioners: a qualitative study

Abstract Background The National Health Service (NHS) seems appropriately placed to be an exemplar employer in providing effective and proactive workplace health and wellbeing services for its staff. However, NHS staff sickness absence costs an estimated £2.4 billion. Evidence suggests staff health and wellbeing services delivered in the NHS can improve health, productivity and sickness absence and yet the adoption of these services remains a challenge, with few examples nationally. This research aimed to explore the perceptions of NHS senior leaders and health and wellbeing practitioners regarding barriers and facilitators to implementing workplace health and wellbeing services for staff in the NHS. Methods Semi-structured interviews were conducted with NHS staff, consisting of four senior leaders, four heads of department and three health and wellbeing practitioners in one region of the UK. Interviews were transcribed verbatim and analysed using thematic analysis. Results Themes describe the experience of delivering workplace health and wellbeing services in the NHS, and barriers and facilitators to implementation from senior decision makers. Barriers to implementation of services include; a busy and pressurised environment, financial constraints and reluctance to invest in staff health and wellbeing. Barriers to staff engagement were also reported and include difficulty of access to health and wellbeing services and lack of time. Initiating services were facilitated by financial incentives, a supportive organisational structure and culture that takes a preventative, rather than reactive, approach to staff health and wellbeing. Facilitators to implementing health and wellbeing services include a coherent, strategic approach to implementation, effective communication and advertisement, being creative and innovative with resources and conducting a needs analysis and evaluation before, during and after implementation. Conclusions Barriers to the successful initiation and implementation of health and wellbeing services in the NHS are numerous and range from front-line logistical issues with implementation to high-level strategic and financial constraints. Adopting a strategic and needs-led approach to implementation and ensuring thorough staff engagement are amongst a number of factors that facilitate implementation and help overcome barriers to initiation of wellbeing programmes in the NHS. There is a need for a culture that supports staff health and wellbeing in the NHS

Younger women’s experiences of deciding against delayed breast reconstruction post-mastectomy following breast cancer: An interpretative phenomenological analysis

Most women do not reconstruct their breast(s) post-mastectomy. The experiences of younger women who maintain this decision, although important to understand, are largely absent in the research literature. This interview-based study uses interpretative phenomenological analysis to explore the experiences of six women, diagnosed with primary breast cancer in their 30s/40s, who decided against delayed reconstruction. Findings reported here focus on one superordinate theme (decision-making) from a larger analysis, illustrating that the women’s drive to survive clearly influenced their initial decision-making process. Their tenacity in maintaining their decision is highlighted, despite non-reconstruction sometimes being presented negatively by medical teams. Patient-centred support recommendations are made

Integrated care to address the physical health needs of people with severe mental illness : a rapid review

Background People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests that this discrepancy is driven by a combination of clinical risk factors, socioeconomic factors and health system factors. Objective(s) To explore current service provision and map the recent evidence on models of integrated care addressing the physical health needs of people with severe mental illness (SMI) primarily within the mental health service setting. The research was designed as a rapid review of published evidence from 2013–15, including an update of a comprehensive 2013 review, together with further grey literature and insights from an expert advisory group. Synthesis We conducted a narrative synthesis, using a guiding framework based on nine previously identified factors considered to be facilitators of good integrated care for people with mental health problems, supplemented by additional issues emerging from the evidence. Descriptive data were used to identify existing models, perceived facilitators and barriers to their implementation, and any areas for further research. Findings and discussion The synthesis incorporated 45 publications describing 36 separate approaches to integrated care, along with further information from the advisory group. Most service models were multicomponent programmes incorporating two or more of the nine factors: (1) information sharing systems; (2) shared protocols; (3) joint funding/commissioning; (4) colocated services; (5) multidisciplinary teams; (6) liaison services; (7) navigators; (8) research; and (9) reduction of stigma. Few of the identified examples were described in detail and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge from the evidence. Efforts to improve the physical health care of people with SMI should empower people (staff and service users) and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication between professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered. Limitations and future work The literature identified in the rapid review was limited in volume and often lacked the depth of description necessary to acquire new insights. All members of our advisory group were based in England, so this report has limited information on the NHS contexts specific to Scotland, Wales and Northern Ireland. A conventional systematic review of this topic would not appear to be appropriate in the immediate future, although a more interpretivist approach to exploring this literature might be feasible. Wherever possible, future evaluations should involve service users and be clear about which outcomes, facilitators and barriers are likely to be context-specific and which might be generalisable

School nurses' perspectives on managing mental health problems in children and young people

Aims and objectives: To explore the views of school nurses regarding mental health problems in young people and their potential for engaging in mental health work with this client group. Background: Mental health problems in children and young people are an important public health issue. Universal children’s services play a key role in identifying and managing these problems and, while school nurses have an important function in this work, little is known about their views on this aspect of their role. Design: A qualitative research design employing focus group methodology. Method: School nurses (n = 33) were purposively sampled from four school nursing teams in two English cities for a series of focus groups. The focus group data were audio-recorded, transcribed and subsequently analysed using ‘framework’. Results: Four principal themes emerged from the data. In these themes, school nurses were found to value their involvement with the mental health of young people, recognising this as an important area of practice. Several obstacles to their work in this area were identified: heavy workloads, professional rivalries, a lack of confidence and limited education and training opportunities. The importance of support from local specialist mental health teams was emphasised. Conclusions: School nurses can be engaged in mental health work though, as public health specialists, their role should focus on health promotion, assessment, signposting and early intervention activities. To facilitate mental health work, school nurses are able to draw on established interpersonal skills and supportive networks; however, workload and a lack of confidence need to be managed and it is important that they are supported by constructive relationships with local specialist mental health teams. Relevance to clinical practice: This study has implications for nurses and healthcare practitioners interested in enhancing the mental health of children and young people in school settings

Harm-reduction approaches for self-cutting in inpatient mental health settings:development and preliminary validation of the Attitudes to Self-cutting Management (ASc-Me) Scale

IntroductionHarm-reduction approaches for self-harm in mental health settings have been under-researched.AimTo develop a measure of the acceptability of management approaches for self-cutting in mental health inpatient settings.MethodsStage one: scale items were generated from relevant literature and staff/service user consultation. Stage two: A cross-sectional survey and statistical methods from classical test theory informed scale development.Results/FindingsAt stage one N=27 staff and service users participated. At stage two N=215 people (n=175 current mental health practitioners and n=40 people with experience of self-cutting as a UK mental health inpatient) completed surveys. Principal components analysis revealed a simple factor structure such that each method had a unique acceptability profile. Reliability, construct validity, and internal consistency were acceptable. The harm-reduction approaches 'advising on wound-care' and 'providing a first aid kit' were broadly endorsed; 'providing sterile razors' and 'maintaining a supportive nursing presence during cutting' were less acceptable but more so than seclusion and restraint.DiscussionThe Attitudes to Self-cutting Management scale is a reliable and valid measure that could inform service design and development.Implications for practiceNurses should discuss different options for management of self-cutting with service users. Harm reduction approaches may be more acceptable than coercive measures. This article is protected by copyright. All rights reserved.</p

Comparing the effectiveness of a multi-component weight loss intervention in adults with and without intellectual disabilities

&lt;p&gt;Background: The prevalence of obesity in adults with intellectual disabilities (ID) is rising, although the evidence base for its treatment in this population group is minimal. Weight management interventions that are accessible to adults with ID will reduce the inequalities that they frequently experience in health services. This short report compared the effectiveness of weight management in those with and without ID who completed nine sessions of a multi-component weight management programme.&lt;/p&gt; &lt;p&gt;Methods: TAKE 5 is a 16-week multi-component weight management intervention for adults with ID and obesity [body mass index (BMI) ≥30 kg m–2]. This intervention is an adaption of the weight management programme provided by the Glasgow &#38; Clyde Weight Management Service (GCWMS) for adults without ID and obesity (National Health Service based). Fifty-two participants of the TAKE 5 programme were individually matched by baseline characteristics (sex, age and BMI) with two participants without ID of the GCWMS programme. Comparisons in terms of weight and BMI change and rate of weight loss were made for those who attended all nine sessions.&lt;/p&gt; &lt;p&gt;Results: There were no significant differences between the groups in the amount of weight loss (median: −3.6 versus −3.8 kg, respectively, P = 0.4), change in BMI (median: −1.5 versus −1.4 kg m–2, P = 0.9), success of achieving 5% weight loss (41.3% versus 36.8%, P = 0.9) and rate of weight loss across the 16-week intervention.&lt;/p&gt; &lt;p&gt;Conclusions: A multi-component weight loss intervention can be equally effective for adults with and without ID and obesity.&lt;/p&gt

The effectiveness and cost-effectiveness of a participative community singing programme as a health promotion initiative for older people: protocol for a randomised controlled trial

Background The growth in numbers of older people represents a considerable cost to health and social care services in the United Kingdom. There is an acknowledged need to address issues of social exclusion and both the physicial and mental health of this age group. In recent years there has been much interest in the potential contribution of the arts to the health of communities and individuals. There is some evidence that participative singing may be of benefit to older people, however studies to date are limited in number and have lacked rigour. There is therefore a need to build on this knowledge base to provide more quantifiable evidence of both effectiveness and cost efffectness of singing as a health intervention of this population group. Methods The proposed study is a pragmatic randomised controlled trial with two parallel arms. The primary hypothesis is that singing groups for older people improve both physical and mental aspects of qualaity of life when compared to usual activities. Potential participants will be volunteers over 60 years living in the community and recruited through publicity. Eligible and consenting participants will be randomized to either a singing group or a control group. Singing groups will take part in a twelve week planned programme of singing and control groups will continue with usual activities. The primary outcome measure will be the York SF-12, a health related quality of life measure which will be administered at baseline, three and six months after baseline. The study will evaluate both effectiveness and cost-effectiveness. Discussion This study proposes to add to the exisiting body of evidence on the value of singing for older people by using a rigorous methodological design, which includes a power calucation, a standardised intervention and assessment of cost-effectiveness. It should be regarded as a stage in a progressive programme of studies in this area. If group singing is found to be effective and cost-effective it may offer an alternative means to maintaining the health of people in later life